I do not have space here to touch on all of the causal links contributing to the high rate of undernutrition and mortality of young children in Timor-Leste. In any case, on my brief visit to Timor, I am no doubt still unaware of many significant factors. So here I’d like to briefly examine several of those links of greatest concern. I will do little more than list those I’ve already touched on, dwelling more on links that might be overlooked.


Poverty is clearly the root cause of children’s poor health. 60% of Timorese live on less than US$0.80 per day. This enduring poverty has a spectrum of causes, many social and political, which must be addressed if wide-spread poor health is ever to be eradicated. Given Timor-Leste’s rapid economic growth from oil revenues, a distressingly small percentage of the national wealth has been trickling down to the destitute. This gross inequity has many causes, not least of which are hegemony and corruption at the national and international level. Cleary, far greater investment in Health and Education is called for. Educational reform is needed that enables people to critically examine the social determinants of health and take collective action to elect representative, forward-looking leaders.

Nutrition Education

Nutritional education in its current form is not accomplishing what it needs to. This is true at all levels, from university to the mass media to community level. Both methods and content need to be reexamined. A new approach to research (participatory epidemiology) needs to be promoted, with a leading role played by mothers and community health promoters.

Imported Pre-packaged Weaning Foods

There are problem with imported prepackaged weaning foods. Partly as an incentive for them to come to the SISCa gatherings, those mothers whose infants measurably underweight are sometimes given a nutritious weaning food from UNICEF called PlumpyNut. However this incentive may be counterproductive, because rewards those mothers whose babies remain underweight.

However PlumpyNut is often unavailable. So mothers often spend their scare food money on an imported commercial weaning food called SUN, which costs them US$0.50 a package. (Most of the cost of SUN goes into packaging, shipping and promotion,) Since the daily wage only US$0.80 a day, the family’s money soon runs out. So rather than using their limited money to make a low-cost, nutritious weaning food from things like rice, peanuts and cooking oil, mothers typically make a weaning porridge using their home-grown staples: cassava and taro. However these high-fiber tubers are hard for infants to digest. So their bellies fill up with watery, poorly digestible tuber porridges, leaving little room in their stomachs for more nutritious foods (including breast milk, if they are still partially breast feeding.) Thus the babies don’t get enough calories even though their bellies are stuffed full—and they fail to gain weight.

Far more study, with full participation of mothers and PSFs, is needed on the spectrum of interrelated factors that cause the current crisis in underweight children. This needs to be followed by the redesigning of nutritional education so as to better adapt it to this complex local reality.

Lack of Adequate Birth Spacing

Lack of adequate birth spacing also contribute to child (and maternal) malnutrition and death. In the long term Timor’s exceptionally high birth rate –averaging 6 children per couple—jeopardizes the nation’s future food security. (Currently almost 70% of food stuffs are imported, and agricultural objectives are not advancing as quickly as planned.) Equally problematic in the short term, frequent pregnancies and inadequate birth spacing contributes to endemic child undernutrition—in several ways:

  1. When a mother again becomes pregnant soon after giving birth, usually she stops breast feeding. This deprives the earlier infant from breast milk and creates competition for scarce food between the baby and the fetus.

  2. A mother who soon becomes pregnant again doesn’t have enough time to rebuild her blood and her strength. Her next baby is more likely to be born premature and underweight.

  3. A mother who is debilitated by frequent childbirth has a harder time providing for both small children at a same time—and both are more likely to become undernourished.

Frequent pregnancies and large family size have different causes. I was told that Timorese men want lots of children “to prove their manhood.” A more common reason in many countries is economic necessity. For a poor family with little social welfare, having lots of children provides a source of low-cost labor and a greater chance that in later life some of the children will help care for their ailing, aging parents.

Also contributing to the high birth rate is the attitude of the Church. Timor-Leste is 95% Catholic, and the Church forbids reliable contraceptives.

Low Rates of Vaccination

Low rates of vaccination also contribute to children’s undernutrition and death. When a child falls ill with measles or another preventable disease, he or she often looses weight. And those who are already malnourished are at higher risk. In Timor immunization coverage is dangerously low. In part this due to the long distances mothers must go to SISCa centers for vaccination. But in part it is due, once again, to objection by the Church. A bishop in East Timor apparently got upset when he learned that women were routinely injected during pregnancy. Though the vaccine was to prevent neonatal tetanus, the prelate evidently thought the injections were to abort or sterilize the fetus. So he launched a campaign of fear, saying all vaccines are harmful. As a result, so many families refuse immunization that recently there was an epidemic of measles in Timor. And because so many are malnourished, the death rate from pneumonia as a complication of measles was unusually high.


HIV-AIDS, while still not prevalent in Timor, is on the rise and likely to become yet another cause of family distress affecting nutritional status and survival of children. In Timor-Leste more women have AIDS than do men. Tuberculosis is already pandemic, and if AIDS escalates, so will TB. Drug-resistant TB is dangerously on the rise.

The Church is accelerating the spread of AIDS through its prohibition of condom use—which likewise diminishes birth spacing, thus compromising the health and nutritional status of both mothers and children.

The good news is that in Timor there are some progressive Catholics groups—such as Maryknoll Sisters—who advocate vaccination and health-protecting use of condoms, and who valiantly defend the rights of the poor. But they are a small minority.

Unrealistic Restrictions on Family Health Promoters (PSFs)

There are unrealistic restrictions on what Family Health Promoters (PSFs) are taught and permitted to do. They could do more. Given the fact that most of Timor’s population lives in aldeas far from health centers with doctors or nurses, it could save lives to capacitate PSFs to provide a broad range of basic health services in their communities. Such responsibilities might well include:

  • Growth monitoring using homemade scales, including appropriate follow-up for underweight or sick children.

  • Participation in community-based research (participatory epidemiology) to learn more about the causes of child undernutrition and design appropriate courses of action.

  • ***Diagnosis and treatment of common health problems—***including use of antibiotics for pneumonia (see below).

  • Application of vaccines to children and pregnant women at the village level.

  • Health education that is discovery-based and empowering—including and involving mothers, fathers and school children (Child-to-Child).

  • Organization of local Health Committees to cooperate in community projects that address specific local health-related needs, and to make necessary demands of the health authorities.

  • Collaborate with traditional birth attendants and healers, acting as a liaison between these persons and the health system.

Failure to Officially Recognize Traditional Birth Attendanrs (TBAs)

Another big obstacle to mother and child health in Timor-Leste is the Health Ministry’s unwillingness to recognize or work with Traditional Birth Attendants (TBAs). A graph published by the Health Ministry shows that about 20% of babies are delivered by health professionals in hospitals; nearly 30% are delivered by trained midwives (educated women officially trained in childbirth); and half of all babies are delivered by “other.” “Other” refers mostly to traditional birth attendants, who do deliveries in homes and whom most mothers (including city dwellers) prefer. However the graph doesn’t refer to them as TBAs because they are no longer recognized by the Health Ministry—under orders of the World Health Organization (WHO).

Misguided WHO Mandates

Given that TBAs attend the vast majority of births in the remote areas where the titled midwives almost never go, the fact that WHO counsels the MoH not to work with TBAs is makes little sense. If the MoH could provide basic support, back-up, and sterile birth kits to the TBAs, it could have a significant impact on maternal and child health. And the impact could be even greater if TBAs were encouraged to cooperate with Family Health Promoters in pre- and post natal care, including nutrition and immunization.

In addition to obstructing the Health Ministry’s cooperation with TBAs, the WHO has also mandated the disempowerment of community health workers, limiting them to the subservient role as messengers or lackeys of health professionals. This imperious unwillingness to enable community health workers to treat common illnesses (like pneumonia, where prompt local treatment can be life-saving) verges on genocidal.

Delayed and Inadequate Treatment of Pneumonia

Pneumonia is one of the biggest killers of young children, especially ones who are weak or malnourished. Early diagnosis and treatment of pneumonia with antibiotics greatly reduces mortality. Where antibiotics can only be prescribed or given by health professionals, and health professionals are not readily available because of distance or cost, the death rate from pneumonia is especially high. In such circumstances it has been shown—and documented in Lancet—that when community health workers are enabled to diagnose and treat pneumonia promptly with appropriate an antibiotic like amoxicillin, the death rate can be significantly reduced.

We talked about this with the SHARE team and the PSFs, who were eager to learn how to diagnose and treat pneumonia. Rapid, shallow breathing is a diagnostic sign of pneumonia. We taught the PSFs to time the rate of breathing using a pendulum made of a rock tied to the end of a string. A baby (at rest) who breaths faster than a rock swings on 35 cm.of string (which swings 50 times a minute) probably has pneumonia.

There is a strong argument for having Family Heath Promoters learn to recognize the signs of pneumonia and to treat it at once with antibiotics— rather than delaying treatment by requiring it only be done by an (often very distant) doctor. However the current rules—promoted by WHO—strictly forbid community health workers to use antibiotics.

The PSFs understood the importance of early treatment, and wondered what do. The SHARE staff felt that every effort should be made to change the WHO and MoH guidelines. But everyone realized this was unlikely to happen soon—despite the numerous studies and publications proving the rational.

“Then what can we do?” asked one of the PSFs. “When a child’s life is in danger and you can’t get her to a doctor in time, do we follow the rules and let the child die.”

“Sometimes,” I ventured, “You have to decide between following rules and saving lives.”